Traveler's diarrhea is the most common illness in people
traveling from resource-advantaged countries to resource-limited regions
of the globe. Approximately 50% of these types of travelers will
contract diarrhea.

I knew of a group of infectious disease experts traveling to India
together --presumably well versed in how to avoid such things--and
one-half of the group developed it.

I have many patients sending me electronic messages asking me for
their standard 3-day ciprofloxacin prescriptions, "just in
case."

I am guilty of having provided this, along with warnings that we
could make matters worse by giving them Clostridium difficile colitis.

Antibiotics may also increase the risk for post-traveler's
diarrhea irritable bowel syndrome, which can occur in up to 15% of
patients.

Mild traveler's diarrhea is defined as passage of one or two
unformed stools in 24 hours without nausea, vomiting, abdominal pain,
fever, or blood in stools.

What is the evidence for the effectiveness of antibiotics, compared
with other interventions such as loperamide, for mild traveler's
diarrhea?

Tinja Laaveri, MD, of the University of Helsinki, and colleagues
conducted a systematic review on the efficacy and safety of loperamide
for traveler's diarrhea (Travel Med Infect Dis. 2016
Jul-Aug;14[4]:299-312). Fifteen articles were retrieved.

Loperamide was observed to be non-inferior to antibiotics for the
treatment of traveler's diarrhea.

In one study, loperamide was observed to be superior to bismuth,
which is commonly recommended to prevent traveler's diarrhea.

The authors remind us that loperamide is different from
antimotility agents such as diphenoxylate with atropine, as loperamide
has an antisecretory effect at lower doses and decreases motility only
at higher doses.

If you subscribe to the idea that diarrhea helps rid the body of
toxins, be reminded that secretory diarrhea is exploited by the organism
to spread the infestation to as many humans as possible.

The recommended regimen for loperamide is a 4-mg loading dose,
followed by 2 mg after every episode of diarrhea.

Tell your patients not to use loperamide if they are having fever
or bloody diarrhea, or if you suspect they could have C. difficile
colitis (that is, recent antibiotics or other risk factors).

Happy travels.

Dr. Ebbert is professor of medicine, a general internist at the
Mayo Clinic in Rochester, Minn., and a diplomate of the American Board
of Addiction Medicine. Dr. Ebbert has no relevant financial disclosures
about this article.

BY JON O. EBBERT, MD

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